Doctor glut in pipeline

Hey there, time traveller!This article was published 14/10/2013 (1151 days ago), so information in it may no longer be current.

VANCOUVER -- Earlier this year, the Paris-based Organization for Economic Co-operation and Development released the results of a survey of average waiting times for medical care in 25 countries. This was not a shining moment for Canada.

Waits for most medical services are far longer here than in most of the comparator countries. This is simply the latest evidence seemingly supporting the rhetoric of a "doctor shortage" that has been a recurring theme in the Canadian public discourse for the past 20 years. But let's take a closer look at the evidence.

Over the past 15 years, first-year medical school enrolments in Canada have almost doubled, from 1,575 in 1997-98 to about 3,000 in 2012-13. The number of foreign medical graduates entering practice in Canada annually has also more than doubled since the year 2000. Over that same period, the number of Canadians who obtained their medical degrees internationally and entered practice in Canada annually has increased 250 per cent.

The Canadian Institute for Health Information (CIHI) reports released this week indicate that between 2008 and 2012, the number of physicians rose three times faster than the growth of the overall population, and for the sixth year in a row, the number of physicians per population has reached a new peak and is continuing to rise.

While this need not necessarily translate into equivalent amounts of additional care provision, it does highlight some troubling trends. We are just beginning to see the effects of the expansion in domestic training capacity. In other words, we are in the early stages of a dramatic expansion in physician supply that will continue for decades.

Canada will soon have too many doctors. Contrary to the continuing doctor-shortage rhetoric from ill-informed or interested parties, a "physician glut" appears already to be in the pipeline.

But, we are told, Canada needs more doctors because the population is aging. True enough, but every study ever done has found that demographic change adds only about 0.5 per cent annually to per capita use of services.

Well, what about the women? The physician workforce is becoming increasingly feminized and female physicians put in fewer hours per year over a lifetime of practice; so goes the argument. Moreover younger male physicians are also working fewer hours than their predecessors. So, many more doctors will be needed.

But again, the awkward facts intrude. Average medical expenditures per physician in Canada (adjusted for fee changes) have been rising, not falling, even as the overall supply expands and becomes increasingly female. If average hours of work are falling, how is it that adjusted payments per physician are rising? Either physicians are delivering more services per hour, or their fees are actually rising much more quickly than the official fee schedules show (or both).

And if they are finding ways to deliver more care, in spite of putting in fewer hours, how is it that we need more doctors?

None of this denies the fact some patients continue to have difficulty finding family doctors, and face excessive waiting times, particularly for certain specialists and some diagnostic tests and surgeries. But evidence is beginning to emerge of Canadian-trained doctors who cannot find work. We suspect this is the beginning of a new and unfortunate trend.

Nevertheless, some pundits and politicians advocate pumping more doctors into the system by making it easier for Canadians studying medicine abroad (CSAs) or foreign-trained medical graduates (FMGs) to enter practice in Canada.

This would be an obvious response to a doctor shortage -- if there was one. An estimated 3,570 Canadians are currently studying medicine at schools in the United Kingdom, Australia, Poland, the Caribbean and elsewhere. Assuming a four-year training program, these CSAs represent a potential increase to domestic supply of nearly 900 new physicians per year, well above the numbers of CSAs entering presently.

Alas, a barrier stands in their way: To enter practice they must not only pass Canadian qualifying examinations and complete residency (specialty) training here; but there are far fewer residency positions available for CSAs than there are CSAs looking for them. Should Canada create and fund more residency slots for them? At another time and place, the case might be compelling. But not here, and certainly not now.

What is needed, instead, is a comprehensive and co-ordinated set of national policies that recognize the reality of the new domestic training situation, and use the opportunity to better manage the overall system, and get physicians with the right training, expertise and resources to where they are needed.

Morris Barer is an advisor with EvidenceNetwork.ca, professor in the centre for health services and policy research, school of population and public health, University of British Columbia, and the lead for the western hub of the Canadian Health Human Resources Network (CHHRN). Robert Evans is an emeritus professor of economics, UBC.

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